What are the symptoms and treatment of carotid dissection?

Symptoms and Treatment of Carotid Dissection

Carotid artery dissection typically presents with pain on one side of the head or neck, accompanied by Horner syndrome (asymmetrical ptosis, miosis, and anhidrosis), followed by cerebral or retinal ischemia in 50-95% of cases. 1

Clinical Presentation

Common Symptoms

• Pain: Unilateral head or neck pain is often the first symptom
• Horner syndrome: Classic triad of:
  • Ptosis (drooping eyelid)
  • Miosis (constricted pupil)
  • Anhidrosis (reduced sweating)
• Cerebral or retinal ischemic symptoms (occurring in 50-95% of cases):
  • Motor deficits (weakness of hand, arm, face)
  • Sensory deficits
  • Aphasia (if left hemisphere affected)
  • Hemineglect (predominantly in right hemisphere)
  • Visual disturbances
  • Transient ischemic attacks (TIAs)
  • Stroke

Less Common Presentations

• Pulsatile tinnitus
• Cranial nerve palsies
• Sudden catastrophic neurological events
• "Stuttering stroke" or symptom progression over hours to days

Diagnostic Approach

Imaging Modalities

1. First-line imaging:

   • Contrast-enhanced CTA or MRA (Class I recommendation) 1
   • These have largely replaced catheter-based angiography

2. Additional imaging:

   • Carotid duplex ultrasonography may identify a dissection flap and differential flow in true and false lumens
   • Catheter-based contrast angiography may be needed in select cases

Diagnostic Challenges

• Dissections beginning above the angle of the mandible may not be detected by ultrasound
• Brain imaging should be performed first, followed by vascular imaging when ischemia is suspected

Treatment

Antithrombotic Therapy

• Primary treatment approach: Antithrombotic therapy for at least 3-6 months (Class IIa recommendation) 1

• Options include:

  1. Anticoagulation:
     • Heparin followed by warfarin
     • Low-molecular-weight heparin
  2. Antiplatelet therapy:
     • Aspirin
     • Clopidogrel
     • Extended-release dipyridamole plus aspirin

• After initial treatment and symptom resolution, antiplatelet therapy may replace anticoagulation, though optimal timing for this transition remains undefined 1

Revascularization

• Reserved for: Patients with persistent or recurrent symptoms despite antithrombotic therapy (Class IIb recommendation) 1
• Options include:
  1. Surgical approaches:
     • Direct carotid repair
     • Resection with vein graft replacement
  2. Endovascular approaches:
     • Carotid angioplasty with or without stenting

Blood Pressure Management

• Beta-adrenergic antagonists, angiotensin inhibitors, or nondihydropyridine calcium channel antagonists may be considered to reduce arterial wall stress, though their effectiveness is not well established (Class IIb recommendation) 1

Important Clinical Considerations

Risk Factors

• Minor trauma (hyperflexion/hyperextension of neck)
• Chiropractic manipulation
• Coughing or nose blowing
• Connective tissue disorders (Ehlers-Danlos syndrome, Marfan syndrome)
• Fibromuscular dysplasia (associated with ~15% of carotid dissections)
• Penetrating trauma
• Amphetamine abuse

Prognosis

• Generally favorable with conservative management
• Carotid dissection accounts for approximately 2% of all ischemic strokes but up to 15% of ischemic strokes in younger patients 1

Monitoring

• Follow-up imaging is important to monitor healing of the dissection
• Most patients achieve anatomic and symptomatic resolution with conservative management 2

The early recognition of carotid dissection symptoms is crucial for timely intervention to prevent stroke, which remains the most serious complication of this condition.